Abstract/Description

EXECUTIVE SUMMARY: Introduction: This report details findings from a study undertaken by the School of Primary Care, Severn Deanery and the School of Health and Social Care, Faculty of Health and Life Sciences, University of the West of England, Bristol (UWE) between November 2008 and November 2009 to evaluate and develop GP appraisal processes in an area in the South West of England.
A process of licensing for all doctors practising medicine in the UK is currently being implemented by the General Medical Council (GMC). All licensed doctors will need to demonstrate at regular intervals that their practice meets the generic standards set by the GMC, as described in Good Medical Practice (GMC 2006). Licensing will involve a process of revalidation for individual practitioners. It is planned to incorporate revalidation into the current appraisal processes for all medical professionals (GMC 2008).
Although a statutory requirement, GP appraisal has until recently had primarily a formative, developmental purpose (DH 2002). Despite being obligatory, the uptake of GP appraisal has been problematic and inconsistent (Martin et al 2003). To date, only a limited amount of research or evaluation about GP appraisal has been published. However, there is recognised tension between the concept of appraisal as both a supportive developmental process and as a measure for judging fitness to practise.
STUDY AIMA: This study set out to evaluate existing evidence submitted by GPs for the purposes of appraisal, and to explore how a model for appraisal could be developed that meets the needs of revalidation but also acts as a developmental process for individual GPs.
METHODS: Both qualitative and quantitative methods were used for this study, in order to provide both breadth and depth to the evaluation. Quantitative data sources comprised all the appraisal evidence checklists used by appraisers in one Primary Care Trust (PCT) over the financial year April 2008 to May 2009 (n=123). The evidence checklist provides a basic template for recording the types of evidence a GP appraisee submits for appraisal purposes, and whether the evidence submitted relates to an individual’s personal practice, or to organisational practice within the GP practice as a whole. Data were analysed using descriptive statistics. Comparative analysis of types of evidence was conducted for appraiser, appraisee age and appraisee status.
Qualitative data were collected through 5 focus groups held with 23 attendees at a GP appraisal stakeholder event hosted by the Deanery, and through interviews with all the appraisal leads for PCTs within the Deanery’s geographical area (n=7). Data were analysed thematically.
The study was approved by a University research ethics sub-committee.
MAIN FINDINGS AND POINTS FOR CONSIDERATION: Findings from this study raise particular points for consideration in relation to the appraiser role; the nature of evidence required for appraisal; the situation of sessional doctors; appraisee age; sharing expertise and experience; and the role of the Deanery in appraisal.
Appraiser role: Most focus group and interview participants were adamant that appraisal should retain a strong developmental element. Clear definition of the role and appropriate national training were seen as essential factors contributing to the success of the process.
Evidence required for appraisal: A notable feature of the focus group data was the confusion expressed by many participants about the nature and amount of evidence required for appraisal. Given the perception that appraisal for revalidation is extremely time-consuming for individual GPs, it was felt that having a clear brief about the evidence required is essential. The revised RCGP guidelines published after these data were collected (RCGP 2009, 2010) may go some way to ameliorating this problem, particularly with respect to the description of what constitutes audit for appraisal purposes.
Sessional doctors: Many focus group participants and at least one appraisal lead were concerned that sessional doctors would have problems collecting the required evidence for appraisal. However, the data from this study also suggest that these problems can be addressed. The checklist data revealed very few substantive differences between principal and sessional doctors with regard to evidence submitted for appraisal. In particular, there was no statistically significant difference between the proportions of principal and sessional doctors who provided supporting information concerning their personal practice in relation to significant events, data or audit collection, multi-source feedback and complaints; this was notable, as these four areas have been identified as potentially problematic for sessional doctors (RCGP 2009, 2010). A number of the study participants were able to provide anecdotal evidence concerning innovative practice among sessional doctors with respect to the collection of evidence for appraisal, both at personal and collective levels. All these data, taken together, suggest that sessional doctors’ problems in this regard may be overstated, as long as appropriate support is provided by employing practices and PCTs.
Appraisee age: The stereotype of the older GP, near retirement and not computer-literate, and not wishing to engage with appraisal, was present in the data. However, this was counterbalanced by examples of exceptions, and concern expressed about some younger, part-time GPs, whose personal circumstances do not support their involvement in appraisal. No differences were found in the checklist data between younger and older GPs with regard to the evidence they provided for appraisal. This applied to all GPs, and also only to locum GPs. It appears that difficulties encountered arise due to individuals’ particular circumstances or personalities, rather than because they belong to a defined category of appraisee.
Sharing expertise and experience: A very strong feature of the qualitative data was the extent to which participants enthused about the benefits they experience when presented with opportunities for sharing expertise and experience. A number of suggestions concerning format were made, including both face to face and on-line media.
The role of the Deanery in appraisal: There was no consistency with regard to participants’ opinions about the degree to which the Deanery should be involved in the co-ordination of the appraisal process. However, all the participants, both from the focus groups and the appraisal leads, were clear that the Deanery has a valuable role to play in training and preparation for appraisal for both appraisers and appraisees. They welcomed the idea that the Deanery could provide fora for sharing expertise and experience, as well as providing structured, dedicated preparation for appraisees. The Deanery was also thought to be well placed to help address any lack of consistency among appraisers through appropriate training.
RECOMMENDATIONS:
1. Change the organisational culture of practices and trusts to encourage access for sessional and locum doctors to Clinical Governance, Significant Event, Audit and Data Collection, through meetings and improved communication. This could be accelerated by including locum access as a quality criterion to be reviewed at practice inspections by PCTs or by the Care Quality Commission.
2. Encourage, establish and facilitate fora and self directed groups for isolated locums and sessional GPs.
3. Provide examples of innovative ways of collecting evidence for this group.
4. Establish new tools designed specifically for this group, such as patient and colleague feedback.